INSURANCE



|Title: |INSURANCE |

|Purpose: |Birth to Three programs must work with the CT Birth to Three System to maximize the revenue from insurance coverage to |

| |support Part C services. |

Overview

The Birth to Three State Statute 17a-248g requires that programs assist in the billing of private insurance for Birth to Three Services. The Affordable Care Act (ACA) restricts the use of financial limits so insurance companies may equate these dollar limits to another unit of measure.

The CT Birth to Three System has a contractor to process all direct service billing for children who are covered by Medicaid and commercial insurance coverage. In order to be paid, all EIS Programs are required to work with the billing contractor to maximize the revenue from Medicaid and commercial insurance. The state will only pay for unpaid claims when service data has been entered within 10 business days of the event and the insurance data is correct. Claims denied due to untimely filing will not be paid by the lead agency.

Insurance Billing Requirements

State statutes and regulations combined with this procedure ensure that the state meets the following requirements of the IDEA Part C Regulations: (1) the Connecticut Birth to Three System will not disclose any personally identifiable information for the purpose of billing commercial insurance or Medicaid without parental consent, (2) coverage for Birth to Three services will not decrease the available annual or lifetime limits for the child or family, (3) the state will not collect insurance plan co-pays or deductibles, (4) the total reimbursement from insurance and parent fees will not exceed the states cost for services, (5) in order to receive early intervention services, parents are not required to sign up for, or enroll in Medicaid or commercial health insurance programs and can withdraw consent to bill health insurance at any time, (6) enrollment in Birth to Three will not adversely affect the availability of health insurance to the child, the child’s parent or child’s family members, and (7) will not result in any increase in premiums or discontinuation of Medicaid or insurance benefits for the child or the child’s family. The parent is responsible for paying premiums.

Pre/Prior Authorization (PA)

Because Birth to Three is covered by a state insurance statute and the Affordable Care Act, the number of Pre/Prior Authorizations (PA) that will be needed is expected to be small. PCG will be able to determine quickly if a claim is rejected because PA is needed. That information will show up in EIBilling and then programs will need to contact the carriers to find out what the carrier needs and send it to them. This shouldn’t stop services from being delivered. Escrow payments will pay for claims that are denied until PA process is complete. Programs are expected to work PA requests once it is identified and this will be monitored. As programs learn which carriers need PA they can do the work up front to save time and increase the revenue to the system. Once some time has passed and we have data to analyze, we can work with programs and PCG to determine the best course for handling PAs that will be the most efficient and result in the most claims being paid quickly. The Lead Agency will monitor use of escrow funds and the PA process.

Form 1-3: Insurance Data Collection and Consent to Release Information

Prior to completing an evaluation, EI programs must accurately collect the required information on the Insurance Data Collection Form 1-3. The data must be entered in a timely manner and the original form is placed in the child’s record. Based on the protections in the Affordable Care Act and state statute, Form 1-3 is not completed to secure the family’s consent to bill insurance but secures their consent to share personally identifiable information with the billing contractors, CMS and/or the family’s insurance carrier(s).

The billing contractor will validate insurance policies based on the data entered into the Birth to Three data system. There will be notification in the billing contractor’s web portal if more information is needed to validate the policy.

Some plans may require prior authorization and the Birth to Three billing contractor will assist with notifying programs when this is true after a claim has been denied.

If the carrier requests additional information such as a copy of the evaluation, a copy of IFSP, or a contact note the EI Program will work with the carrier directly.

Informed Consent to Bill Health Insurance Plans

Exempt from State Insurance Mandates

Insurance plans that are not required to follow state mandates (plans that are self-funded by an employer, also called ERISA, non-mandated plans, or plans written by companies that do not sell health insurance in Connecticut) may not pay or, if they do, may not offer the protections required by state statute.

EI Programs should explore with families whether their insurance falls into this category and when it is determined to be so, offer the family Form 1-3a, Informed Consent to Bill Health Insurance Plans Exempt from State Insurance Mandates.

The policy validation process completed by the billing contractor will confirm whether the family’s insurance plan is non-mandated. Form 1-3a ensures that families understand that their plans may not be protected.

Because it is not always apparent which plans are mandated, if a parent signed form 1-3 and the billing contractor discovered that the plan is non-mandated, the program should ask the family to complete Form 1-3a and update Form 1-3 if needed. If they sign that they do not grant permission on 1-3a, the program must then indicate that the consent on Form 1-3 has been revoked and change the information in the data system to indicate that the family will be charged the additional monthly fee. The family will not be asked to pay the higher amount retroactively.

Informed Consent to Use a Health Reimbursement Agreement (HRA) or

a Health Savings Account (HSA)

Many families may not know whether they have a Health Reimbursement Agreement (HRA) or a Health Savings Accounts (HSA), the Birth to Three System will not bill HRAs/HSAs without a family’s informed consent.

HRAs are a special account funded by an employer to pay for current and future medical expenses and are used in conjunction with a High Deductible Health Plan.

HSAs are a special account owned by an individual used to pay for current and future medical expenses and are used in conjunction with a High Deductible Health Plan (HDHP). The HSAs are a means by which a family or individual with a specific HDHP is allowed to set aside pre-tax money to cover the high deductible. When a claim is processed, the owner of the HSA is allowed to make the determination whether he or she wants the claim to be paid out of the HSA or their own pocket. Some HRAs and HSAs have automatic options that will pay the deductible portion of the claim which is not in line with the Birth to Three policy of not collecting the deductible from the family. This creates a problem in that the program would be required to return the money if it were, in fact, paying the deductible.

When it is clear that a family has an HRA/HSA the program should explain Form 1-3HSA if the family knows that their deductible has already been met. Signing Form 1-3 HSA for a limited time will allow programs to bill for Birth to Three services.

Flexible Spending Accounts

Flexible Spending Accounts are sponsored by the parent’s employer. It allows the parent to set aside “pre-tax” dollars for medical expenses. The account is managed by the parent and can include an automatic withdrawal option. If the automatic withdrawal option is activated, any portion of the insurance claim not covered by the insurance carrier can then be withdrawn and either mailed to the provider processing the claim or directly to the family. The potential could be to totally deplete the flexible spending account prematurely or to accidentally charge the family for co-pays, deductibles or unreimbursed claims. Programs would be responsible for reimbursing families if this happens. The automatic withdrawal option should be discussed with the parent who could inquire about deactivating the option or at least be aware of the potential possibilities.

Consent to Bill Insurance and Family Cost Participation

For families with annual incomes of $45,000 or more that do not authorize billing of their insurance (mandated and non-mandated alike), the Birth to Three System will impose a monthly fee in addition to the monthly family cost participation fee. The additional fee will range from $8.00 to $75.00 a month depending on the family‘s reported annual income level. (See the current system of payments for the detailed amounts.)

Insurance Payments Received By Families

State law requires Connecticut insurance companies to reimburse for early intervention services provided by EI programs. If the reimbursement by the insurance company is received by the family, the family is obligated to reimburse the program as stated on Form 1-3. The Explanation of Benefits (EOB) will alert either the billing contractor or the program that a family has received an insurance check and has not reimbursed the program.

If the family fails to return the funds to the EI Program and the amount equals to at least three months of the parent’s cost participation fee (as applicable), the EI Program will notify the billing contractor who will send the family written prior notice that services will suspended until the family pays the full amount they received.

Discounts Requested By Insurance Companies

through Claims Processing Companies

Any forms received from claims processing companies (e.g. MultiPlan or OmniClaim) requesting the Birth to Three program to accept a discounted payment for Birth to Three claims, should be forwarded to the billing contractor immediately upon receipt.

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